Notification of Changes for Business Entity
General Information
Business Entity Name:	ALLEGIANT HEALTH PLAN SERVICES LLC
Incorporation / Formation Date:	09/14/216
FEIN:	81-0921345
Ohio License Number:	1132559
NPN:
DBA / Trade Name:
State of Domicile:	OH
County:	MAHONING
Business Address
Address 1:	1305 BOARDMAN-CANFIELD RD.
Address 2:
City:	BOARDMAN
State:	OH
Zip:	44512
Phone:	3309659555
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	1305 BOARDMAN-CANFIELD RD.
Address 2:
City:	BOARDMAN
State:	OH
Zip:	44512
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date
CHARLES STEVENS	PARTNER	2256033		YES	08/15/217
MALLORY MCCORKHILL	PARTNER	17296086	YES		08/15/217

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)	NO
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?	NO
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	ANGELO M. BABBARO
Title:	PRESIDENT
Phone Number:	3309659555
Email Address:	ANGELO@THEBABBAROGROUP.COM